Airway and Perioperative Management


7
Airway and Perioperative Management


Jared Sheppard, MD, Jeffrey P. Coughenour, MD, and Stephen L. Barnes, MD


Division of Acute Care Surgery, Department of Surgery, University of Missouri, Columbia, MO, USA



  1. A 57‐year‐old man with a history of hypertension, hyperlipidemia, obstructive sleep apnea, and obesity (BMI 45 kg/m2) is in your step down unit following a motor vehicle crash (MVC) 3 days ago, in which he sustained multiple bilateral rib fractures with associated pulmonary contusions. Initially, he required only nasal cannula to maintain a SpO2 of 92%, but now requires heated high‐flow nasal cannula at 70 L/min and 100% FiO2, with a saturation of 86%. The decision is made to intubate. After giving RSI, you perform bag/mask ventilation to preoxygenate; however, you note significant difficulty with increasing his SpO2. Which one of the following predicts difficulty of bag/mask ventilation?

    1. Age > 40 years
    2. BMI > 35 kg/m2
    3. Neck circumference > 30 cm
    4. Facial hair
    5. Dentures

    Effective oxygenation and ventilation, while important, may be impossible in certain patient populations. While there is some dispute as to which factors are most predictive of bag‐mask ventilation failure, Cattano et al. found the following to predict difficulty in BVM in the general surgical population: Age greater than 50 years old, BMI greater than 35, neck circumference greater than 40 cm, history of obstructive sleep apnea, history of difficult intubation, facial hair, and perceived short neck.


    Answer: B


    Saghaei M, Shetabi H, Golparvar M. Predicting efficiency of post‐induction mask ventilation based on demographic and anatomical factors. Adv Biomed Res. 2012; 1:10. doi: 10.4103/2277‐9175.96056. Epub 2012 May 11. PMID: 23210069; PMCID: PMC3507007.


    Cattano D, Killoran PV, Cai C, Katsiampoura AD, Corso RM, Hagberg CA. Difficult mask ventilation in general surgical population: observation of risk factors and predictors. F1000Res. 2014; 3:204. Published 2014 Aug 27. doi: 10.12688/f1000research.5131.1.


  2. A 78‐year‐old woman with a history of COPD (80 pack‐year history of cigarette smoking), peripheral vascular disease, hyperlipidemia, and malnutrition is admitted to your surgical ICU following a Whipple procedure for pancreatic adenocarcinoma, and remains intubated due to a mixed respiratory and metabolic acidosis. A medical student on service in the ICU asks if perioperative smoking cessation would have been of any value in this patient. You respond:

    1. Any amount of smoking cessation prior to a major operation has been shown to improve surgical site infection.
    2. Smoking cessation for at least 8 weeks duration has been shown to decrease cardiovascular complications.
    3. Smoking cessation for at least 4 weeks preoperatively reduces respiratory complications and wound‐healing complications.
    4. Smoking cessation for 4 weeks only decreases wound‐healing complications, but does not have a significant effect on respiratory complications.
    5. Smoking cessation for 2 weeks shows some reduction in wound‐healing and respiratory complications.

    Smoking history drastically increases the chance of perioperative complication, especially in regard to wound‐healing and respiratory complications. Wong et al. showed that 4 weeks of abstinence improved respiratory outcomes, while 2–3 weeks abstinence improved wound‐healing complications without a significant effect on respiratory status. Mills et al. conducted a systematic review of randomized trials on smoking cessation and found that while 4 weeks smoking cessation had a significant improvement over less than 4 weeks, there was a nearly 20% increase in magnitude of effect for each week of cessation.


    Answer: C


    Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta‐analysis. Am J Med. 2011; 124(2):144–154.e8. doi: 10.1016/j.amjmed.2010.09.013. PMID: 21295194.


    Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short‐term preoperative smoking cessation and postoperative complications: a systematic review and meta‐analysis. Can J Anaesth. 2012; 59(3):268–279. doi: 10.1007/s12630‐011‐9652‐x. Epub 2011 Dec 21. PMID: 22187226.


  3. A 59‐year‐old man with no significant past medical history is referred to your clinic for evaluation of an umbilical hernia. On exam, he has a reducible but tender umbilical hernia with an approximately 2 cm fascial defect. The decision is made to perform open repair. In preparation for his upcoming operation, what testing (if any) is indicated?

    1. No testing is needed
    2. Chest x‐ray C
    3. Chest x‐ray, EKG D
    4. Chest x‐ray, EKG, CBC E
    5. Chest x‐ray, EKG, CBC, BMP

    Appropriate perioperative cardiovascular evaluation is imperative for quality patient care. While traditionally certain tests were indicated solely based on patient’s age, this practice has begun to fall by the wayside. According to current guidelines, a chest x‐ray should be obtained for patients with signs or symptoms of cardiopulmonary disease, patients with COPD without a CXR in the past 6 months, and patients who smoke or who have had recent upper respiratory tract infections. EKG should be obtained for patients with signs and symptoms of cardiovascular disease. A CBC is indicated for patients at risk of anemia based on their history and physical exam, and those in whom significant blood loss is anticipated. BMP should be reserved for patients at risk of electrolyte abnormalities or renal impairment. A UA should be performed in patients undergoing urologic procedures or implantation of foreign material. A pregnancy test should be ordered for all women of reproductive age.


    Answer: A


    Feely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF. Preoperative testing before non‐cardiac surgery: guidelines and recommendations. Am Fam Physician. 2013; 87(6):414–418. PMID: 23547574.


    Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. Can J Cardiol. 2017; 33(1):17–32. doi: 10.1016/j.cjca.2016.09.008. Epub 2016 Oct 4. Erratum in: Can J Cardiol. 2017 Dec;33(12):1735. PMID: 27865641.


    Siddaiah H, Patil S, Shelvan A, Ehrhardt KP, Stark CW, Ulicny K, Ridgell S, Howe A, Cornett EM, Urman RD, Kaye AD. Preoperative laboratory testing: implications of “Choosing Wisely” guidelines. Best Pract Res Clin Anaesthesiol. 2020; 34(2):303–314. doi: 10.1016/j.bpa.2020.04.006. Epub 2020 Apr 22. PMID: 32711836.


  4. A 67‐year‐old woman with a history of atrial fibrillation, that is rate‐controlled with metoprolol, presents with an acute episode of Hinchey III diverticulitis with associated peritonitis on exam. She is taken emergently to the operating room. Regarding perioperative beta blockade, which of the following is true?

    1. While there is considerable controversy regarding initiating beta blockade in patients not currently on beta blockade, patients receiving a beta blocker should be continued on their home dose perioperatively.
    2. Initiation of beta blockade during the perioperative period has been shown to reduce cardiovascular complications, while not changing overall mortality.
    3. Initiation of a beta blockade during the perioperative period has been shown to reduce cardiovascular complications and improve mortality.
    4. Patients with known CAD not currently on beta blockade and undergoing a high‐risk operation should be initiated on a high‐dose beta blocker.
    5. Perioperative beta blockade should only be given to patients undergoing high‐risk cardiac surgery, regardless of home prescription.

    Following Mangano’s publication, beta blockade was considered one of the most effective means of protecting patients from adverse cardiac events during noncardiac surgery. However, results were mixed in various trials that followed. The POISE trial was conducted as an attempt to demonstrate conclusive evidence for or against perioperative beta blockade. The trial, published in 2008, demonstrated cardiac protection, but also showed an increase in mortality, CVA, and hypotension in patients initiated on beta blockade in the immediate preoperative period. However, this study implemented high doses of beta blockade, and was thus criticized. Studies that followed have had mixed and similarly criticized results. What has been consistently shown is that there is benefit in continuing home beta blockade, and new beta blockade should likely be initiated in patients with high cardiac risk undergoing high‐risk procedures, but high‐dose beta blockade should be avoided.


    Answer: A


    POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of extended‐release metoprolol succinate in patients undergoing non‐cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008; 371(9627):1839–1847. doi: 10.1016/S0140‐6736(08)60601‐7. Epub 2008 May 12. PMID: 18479744.


    Foex P, Sear JW. II. β‐Blockers and cardiac protection: 5 yr on from POISE. Br J Anaesth. 2014; 112(2):206–210. doi: 10.1093/bja/aet437. Epub 2013 Dec 15. PMID: 24343158.


    Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996; 335(23):1713–1720.


  5. A 63‐year‐old man with a history of CAD status post CABG, HLD, HTN, and COPD is seen in your clinic for evaluation of a symptomatic right inguinal hernia, and the decision is made to perform an open repair. He states that he has had no shortness of breath or noted any cardiopulmonary symptoms. The patient asks if he should continue his daily aspirin and statin before his operation (scheduled for 14 days from now). You advise him:

    1. There are significant cardioprotective effects in continuing his statin through the perioperative period; however, he should hold his aspirin due to potential bleeding risk.
    2. Due to his history of CAD, he should continue his aspirin and statin, and should be started on a beta blocker in anticipation of his operation.
    3. The patient should continue his aspirin until 5 days before his operation, and should continue his statin through the perioperative period.
    4. While there is incomplete agreement, most expert panels recommend continuing aspirin for vascular procedures only, and continuing a statin throughout the perioperative period.
    5. The patient should continue his aspirin and statin and does not need to start a beta blocker.

    Perioperative aspirin should be continued for cardiac risk reduction unless there is a prohibitive bleeding risk. Statins have repeatedly demonstrated cardioprotective benefits in the perioperative period through an incompletely defined mechanism. Most evidence had shown benefit to statin use, but primarily in the vascular and cardiac surgery cohort. In 2017, London et al. demonstrated a significant risk reduction in 30‐day all‐cause mortality in patients exposed to statin on the day of surgery or the day following surgery, who underwent vascular, general, neurosurgical, orthopedic, thoracic, urologic, or otolaryngologic procedures.


    Answer: E


    Holt NF. Perioperative cardiac risk reduction. Am Fam Physician. 2012; 85(3):239–246. PMID: 22335263.


    London MJ, Schwartz GG, Hur K, Henderson WG. Association of perioperative statin use with mortality and morbidity after major noncardiac surgery. JAMA Intern Med. 2017; 177(2):231–242. doi: 10.1001/jamainternmed.2016.8005. PMID: 27992624.


  6. A 34‐year‐old woman arrives in your trauma bay following an MVC in which she was the ejected driver. She was unresponsive at the scene, with hypotension and tachycardia noted by EMS. Upon arrival to the trauma bay, she has a GCS of 6 with a HR of 130, BP 106/89, SpO2 of 91% on facemask, and has a respiratory rate of 28. She has scattered abrasions on her trunk, and FAST exam demonstrates fluid in the RUQ, as well as a gravid uterus. Which of the following is true in regard to this patient’s pregnancy?

    1. Her pulmonary status and likelihood of first attempt success at intubation are unchanged compared to a nonpregnant counterpart.
    2. A chest tube should be placed approximately 3–4 rib spaces higher than in the nonpregnant patient.
    3. She is more susceptible to metabolic acidosis than a nonpregnant counterpart.
    4. This patient likely has a higher end‐tidal CO2 than a nonpregnant patient.
    5. Her risk of intra or retroperitoneal hemorrhage is lower than in a nonpregnant patient.

    The physiologic changes of pregnancy are important to know, especially in the trauma patient, and are summarized below:


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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Airway and Perioperative Management

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